Provider First Line Business Practice Location Address: 
2736 FLORIDA BLVD
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
BATON ROUGE
    Provider Business Practice Location Address State Name: 
LA
    Provider Business Practice Location Address Postal Code: 
70802-2719
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
225-383-9139
    Provider Business Practice Location Address Fax Number: 
225-336-5431
    Provider Enumeration Date: 
05/16/2007